A challenge to diagnostic assumptions

Current psychiatric frameworks tend to associate depression with functional impairment.^{Reference Gonda, Pompili, Serafini, Carvalho, Rihmer and Dome3,Reference Chow, Bowie, Morton, Lalovic, McInerney and Rizvi4} In contrast, individuals with HFD often retain high performance in professional or caregiving roles while concealing symptoms. Many may describe themselves as ‘just tired’ or ‘coping under pressure’. In such contexts, clinicians may misattribute signs of distress to occupational stress, personality traits such as perfectionism, or situational burnout.^{Reference Kim, Zeppenfeld and Cohen5,Reference Baumeister, Dale and Sommer6}

Furthermore, conventional screening tools such as the Patient Health Questionnaire-9 or General Anxiety Disorder-7 may inadequately capture subthreshold but persistent symptoms in individuals who minimise their distress.^{Reference Villarreal-Zegarra, Barrera-Begazo, Otazú-Alfaro, Mayo-Puchoc, Bazo-Alvarez and Huarcaya-Victoria7} This diagnostic ambiguity may delay intervention until the individual reaches a point of collapse, often presenting in crisis or through somatic complaints.

The challenge is compounded in high-functioning populations such as students, physicians, carers and executives, who are socially and professionally incentivised to appear emotionally self-sufficient.^{Reference Jones2}

The paradox of success and silence

The sociocultural perception of depression is often tied to dysfunction.^{Reference Hirschfeld, Montgomery, Keller, Kasper, Schatzberg and Hans-Jurgen8} However, high-functioning individuals may embody the very traits society rewards: resilience, ambition and self-control. For many, these traits mask vulnerability.^{Reference Kim, Zeppenfeld and Cohen5,Reference Baumeister, Dale and Sommer6}

Women, ethnic minorities and professionals in high-pressure environments may feel an implicit obligation to maintain a composed façade.^{Reference Kim, Zeppenfeld and Cohen5,Reference Baumeister, Dale and Sommer6,Reference Lee9} Studies have found that such individuals often internalise the belief that they are ‘not unwell enough’ to seek help, particularly if their suffering is not externally visible.^{Reference Hirschfeld, Montgomery, Keller, Kasper, Schatzberg and Hans-Jurgen8,Reference Lee9}

This paradox is exacerbated by mass media representations that either dramatise breakdowns or celebrate ‘toughness’ in adversity. The deaths of public figures who appeared successful on the surface highlight the limits of our current diagnostic paradigms.^{Reference Lee9} Yet, clinical reforms rarely follow these public reckonings. Also, the interplay of chronic stress should not be underestimated, as these stressors, be they environmental, neuroendocrinological and/or genetic, further compound the silent progression to a major depressive condition.^{Reference Tafet and Nemeroff10,Reference Tafet and Bernardini11} It is noteworthy that HFD may be preceded and/or triggered by burnout, as their symptoms, masking and treatments most likely overlap.^{Reference Koutsimani, Montgomery and Georganta12}

Clinical and public health implications

Delayed recognition of HFD carries significant risks. Prolonged low-grade depression can evolve into major depressive episodes, increase suicidality and result in comorbid anxiety or substance use disorders.^{Reference Sekowski and Prigerson13} Beyond mental illness, persistent depressive symptoms are linked to cardiovascular morbidity, sleep disturbance and diminished immune function.^{Reference Adroa Afiya14}

Clinically, people with HFD may be reluctant to engage in treatment.^{Reference Baumeister, Dale and Sommer6} This is not due to pharmacological resistance, but behavioural ambivalence. Patients may question the legitimacy of their need for help, feel guilt for seeking care or withdraw from therapy once external performance improves.^{Reference Kim, Zeppenfeld and Cohen5,Reference Baumeister, Dale and Sommer6} Psychotherapeutic approaches such as cognitive–behavioural therapy and compassion-focused therapy may need to be adapted to engage these individuals’ high levels of autonomy, self-criticism and over-control.^{Reference Gautam, Tripathi, Deshmukh and Gaur15}

At a systems level, HFD contributes an invisible burden in primary care workplace environments. Mental health promotion strategies in occupational and educational settings often miss those who are technically ‘functioning’ but quietly deteriorating.^{Reference Kim, Zeppenfeld and Cohen5}

What psychiatry must address

To better serve individuals with HFD, psychiatry must evolve on four fronts.

1. (a) Broadening of screening practices: screening tools should be adapted to include emotional numbing, perfectionistic coping and internalised distress in high-performing populations.

2. (b) Recognising subthreshold depression: diagnostic frameworks such as the DSM and ICD should better acknowledge persistent, functionally masked depression and associated distress, as should practice guidelines such as those published by National Institute for Health and Care Excellence (NICE), American Psychiatric Association and World Health Organization.

3. (c) Ensuring cultural and identity awareness: training should equip clinicians to recognise how gender, culture and socio-professional identity influence help-seeking behaviours and symptom expression.

4. (d) Developing future research: further research is urgently needed to better understand this form of depression, particularly its prevalence, specific symptoms, screening/diagnostic tools and management modalities, through longitudinal studies on depression trajectories, qualitative exploration of patients’ personal experiences, and targeted interventions within high-functioning occupational groups.